Patient Applications

Steps to Follow

1. Please watch the video below on how to become a patient
2. Complete Eligibility Quiz
3. Receive a phone call from Shifa staff on next steps within 3 business days



Eligibility Requirements



Eligibility Requirements (you must):

  • Have no health insurance
  • Have an income level that falls within 250% of the Federal Poverty Level based on the number of people in your household



Summary of HIPAA Notice of Privacy Practices

Shifa Free Clinic complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Shifa Free Clinic protects confidential health care information, known as “Protected Health Information” (PHI). Below is a summary of your privacy rights under HIPAA. Shifa Free Clinic legal duties and privacy practices regarding your PHI are also included in this Summary Notice.

Summary of Your Privacy Rights

Shifa Free Clinic may use and give your health information to:

  • Treat you
  • Operate health care services

Shifa Free Clinic may use and give your health information for:

  • Law enforcement requests
  • Judicial and administrative proceedings related to legal actions
  • Healthcare fraud and abuse detection or compliance with the law
  • Use by another healthcare provider treating you
  • Government health oversight activities
  • Reports required by law related to births, deaths or diseases
  • Reports required by law related to neglect and abuse, or domestic violence
  • Notifying a party about exposure to a possible communicable disease
  • Military, national defense and security or other governmental functions
  • Workers’ compensation purposes and in compliance with related laws
  • Averting a serious threat to public health and safety

You have the right to:

  • Inspect or get a copy of your medical record
  • Change information on your medical record if you think it is incorrect
  • Get a list of persons with whom Shifa Free Clinic has shared your PHI
  • Ask Shifa Free Clinic to limit the information it shares
  • Ask for a copy of your privacy notice
  • Write a letter of complaint to Shifa Free Clinic or the federal government

If you have any questions, wish to file a complaint, or exercise any rights listed in this Summary or the complete Notice, please contact Shifa Free Clinic at